| NPI | 1366408668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AZ 5242) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 7329) |
| Enumeration Date | 2006-04-25 |
| Last Update Date | 2014-12-03 |