| NPI | 1356415673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CO DEN.00203804) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: IL 021-001744) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2022-09-18 |