| NPI | 1104996974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401413645) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TN 8537) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NY 54900) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2014-03-25 |