| NPI | 1114239464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO 201983) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 28324) |
| 1223G0001X Dentist, General Practice (Licence: TX 28324) | |
| 1223G0001X Dentist, General Practice (Licence: CO 201983) | |
| Enumeration Date | 2010-07-01 |
| Last Update Date | 2016-09-29 |