| NPI | 1275821415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 9689798) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6317) |
| Enumeration Date | 2011-07-20 |
| Last Update Date | 2018-08-14 |