| NPI | 1275071557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN015211) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32668) |
| Enumeration Date | 2017-02-07 |
| Last Update Date | 2021-08-16 |