| NPI | 1225209000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS039530) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401412820) |
| 124Q00000X Dental Hygienist (Licence: PA DS039530) | |
| Enumeration Date | 2008-03-19 |
| Last Update Date | 2020-08-21 |