| NPI | 1164750352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: PA DS037207) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NJ DI02430800) |
| Enumeration Date | 2009-11-26 |
| Last Update Date | 2013-04-04 |