| NPI | 1316558976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE61361584) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00204460) |
| Enumeration Date | 2020-08-16 |
| Last Update Date | 2024-10-10 |