| NPI | 1174507230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CT 009682) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 000031) |
| 1223G0001X Dentist, General Practice (Licence: CT 009682) | |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2021-03-25 |