| NPI | 1215154687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 3704) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: SC 3704) |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2011-05-12 |