| NPI | 1124046826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 0014) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 0014) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN 10833) | |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: MN 10833) | |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2007-07-08 |