| NPI | 1184682585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 3514) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 3514 SPEC 0504) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 0504) | |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2018-01-11 |