| NPI | 1295063980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: ND 2171) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN 390200000X) |
| Enumeration Date | 2009-11-18 |
| Last Update Date | 2014-10-03 |