| NPI | 1306657077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: OK 274) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 7974) |
| Enumeration Date | 2025-01-14 |
| Last Update Date | 2025-01-14 |