| NPI | 1306053350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: ID D4203OR) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 30219) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2023-12-29 |