| NPI | 1295265080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN122837) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022285) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2024-07-24 |