| NPI | 1184171944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 36586) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415349) |
| Enumeration Date | 2016-09-08 |
| Last Update Date | 2020-08-19 |