| NPI | 1104239136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AK 109471) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 30627) |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2016-09-02 |