| NPI | 1386010049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO DEN.00205353) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 64978) |
| Enumeration Date | 2015-08-18 |
| Last Update Date | 2023-05-23 |