| NPI | 1134881550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17246) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: DC DEN2000106) |
| Enumeration Date | 2021-10-13 |
| Last Update Date | 2025-04-08 |