| NPI | 1154389526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MT 2005) |
| Additional Taxonomies | 126800000X Dental Assistant (Licence: AK 1057) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2009-07-22 |