| NPI | 1255536678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MA 21764) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE60034668) |
| Enumeration Date | 2007-06-16 |
| Last Update Date | 2009-05-15 |