| NPI | 1275660037 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 122300000X Dentist (Licence: LA 3729) | 
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: LA 3729) | 
| Enumeration Date | 2007-02-28 | 
| Last Update Date | 2025-04-25 |