| NPI | 1114446564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: AK 149005) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV LL-455-17) |
| Enumeration Date | 2017-09-18 |
| Last Update Date | 2023-05-01 |