| NPI | 1396982088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS040314) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019936) |
| Enumeration Date | 2009-01-16 |
| Last Update Date | 2015-08-27 |