| NPI | 1255960399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 12157) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1504) |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2021-11-23 |