| NPI | 1154095263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA DS041511) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS041511) |
| Enumeration Date | 2021-08-03 |
| Last Update Date | 2021-08-03 |