| NPI | 1366582454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NV S6-142) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 4522T) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2016-07-18 |