| NPI | 1215247911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 28708) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 6088) |
| Enumeration Date | 2010-10-14 |
| Last Update Date | 2014-07-23 |