| NPI | 1215581574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AZ D011441) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001638) |
| Enumeration Date | 2019-07-25 |
| Last Update Date | 2024-03-26 |