| NPI | 1154601292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN R595) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10555) |
| 122300000X Dentist (Licence: IL 019028769) | |
| Enumeration Date | 2011-08-21 |
| Last Update Date | 2014-07-02 |