| NPI | 1154415651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: IA 06051) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 2576-015) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2007-07-09 |