| 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 |