| NPI | 1174931133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: WA DE61155736) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: AZ D009986) |
| Enumeration Date | 2014-07-23 |
| Last Update Date | 2021-05-28 |