| NPI | 1174772784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NM DD3765) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AZ 7520) |
| Enumeration Date | 2008-09-18 |
| Last Update Date | 2014-04-07 |