| NPI | 1366715120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-10408) |
| Additional Taxonomies | 122300000X Dentist (Licence: SD D1504) |
| 122300000X Dentist (Licence: NE 7137) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE60453832) | |
| Enumeration Date | 2012-02-09 |
| Last Update Date | 2026-01-20 |