| NPI | 1407403652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: GA DN122234) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN122234) |
| Enumeration Date | 2019-08-22 |
| Last Update Date | 2024-03-06 |