| NPI | 1215662457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: UT 13766591-9926) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL15300) |
| Enumeration Date | 2022-07-21 |
| Last Update Date | 2024-08-08 |