| NPI | 1376876961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 61236) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855263) |
| Enumeration Date | 2009-09-14 |
| Last Update Date | 2025-02-19 |