| NPI | 1114445616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS042093) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1857469) |
| Enumeration Date | 2017-09-05 |
| Last Update Date | 2019-09-06 |