| NPI | 1134547474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KS 812) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 61712) |
| 122300000X Dentist (Licence: IA DDS-08864) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MO 2013043911) | |
| Enumeration Date | 2014-04-03 |
| Last Update Date | 2019-12-03 |