| NPI | 1346761368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NV S3-358) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901022360) |
| Enumeration Date | 2017-06-29 |
| Last Update Date | 2022-06-22 |