| NPI | 1225609993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 37472) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 37472) |
| Enumeration Date | 2021-07-05 |
| Last Update Date | 2026-04-21 |