| NPI | 1235136037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OR D5783) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D5783) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2007-07-16 |