| NPI | 1154561926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WY 1245) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 1290) |
| Enumeration Date | 2009-03-05 |
| Last Update Date | 2010-07-14 |