| NPI | 1316305352 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2015040188) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NV S3-335C) |
| Enumeration Date | 2016-02-05 |
| Last Update Date | 2019-10-21 |