| NPI | 1124307426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO 00205531) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 056402) |
| Enumeration Date | 2011-08-04 |
| Last Update Date | 2023-10-26 |