| NPI | 1154851681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D11968) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33334) |
| Enumeration Date | 2017-06-18 |
| Last Update Date | 2025-04-08 |