| NPI | 1205980414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: IA 08289) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 08289) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2009-10-14 |