| NPI | 1245599703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO DEN.00203355) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: NJ 22DI02497500) |
| Enumeration Date | 2012-05-03 |
| Last Update Date | 2018-03-17 |