| NPI | 1124519558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS041923) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041923) |
| Enumeration Date | 2018-05-21 |
| Last Update Date | 2021-06-21 |