| NPI | 1316259955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 187) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6097) |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2025-04-29 |