| NPI | 1346643350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS041235) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15586) |
| Enumeration Date | 2014-10-04 |
| Last Update Date | 2021-02-16 |