| NPI | 1336505015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 250) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 6717) |
| Enumeration Date | 2016-01-11 |
| Last Update Date | 2025-06-25 |