| NPI | 1306286380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: CO 00202731) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: UT 6900541-9922) |
| Enumeration Date | 2013-07-05 |
| Last Update Date | 2016-07-07 |