| NPI | 1396795068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: ID D3301PD) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D3301PD) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2008-01-02 |