| NPI | 1336662899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401419241) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1001681-15) |
| Enumeration Date | 2017-07-17 |
| Last Update Date | 2025-11-12 |