| NPI | 1316268915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 9423399) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN-10197) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 1001174) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WI 1001174) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN S108) | |
| Enumeration Date | 2010-06-17 |
| Last Update Date | 2020-12-01 |