| NPI | 1376890467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 36693) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039130) |
| Enumeration Date | 2012-08-08 |
| Last Update Date | 2026-01-18 |