NPI | 1275817645 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9672) |
Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413227) |
1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: ND 2370) | |
Enumeration Date | 2011-10-04 |
Last Update Date | 2023-09-15 |