| NPI | 1205972197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: PA DSO17051L) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: PA DSO17971L) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2007-07-08 |