| NPI | 1235518622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 401415270) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415270) |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2017-05-19 |