| NPI | 1235242801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 26356) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8396) |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2011-09-16 |