| NPI | 1235487851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4852) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00201838) |
| Enumeration Date | 2012-08-29 |
| Last Update Date | 2021-10-26 |