| NPI | 1255647699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 30524) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 054532-1) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NM DD4209) | |
| Enumeration Date | 2010-08-24 |
| Last Update Date | 2014-12-08 |