| NPI | 1134647910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 11725) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NC 11725) |
| Enumeration Date | 2017-08-31 |
| Last Update Date | 2022-02-26 |