| NPI | 1396808317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: SC 631) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4149) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2008-06-09 |