| NPI | 1205934072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: IA 08305) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401006834) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2020-10-02 |