| NPI | 1255737151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA DDS101428) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6569) |
| Enumeration Date | 2014-11-05 |
| Last Update Date | 2017-07-12 |