| NPI | 1306008057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2009012760) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D008162) |
| Enumeration Date | 2008-06-25 |
| Last Update Date | 2011-03-22 |