| NPI | 1417366881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS039961) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039961) |
| Enumeration Date | 2014-08-10 |
| Last Update Date | 2018-04-03 |