| NPI | 1457098865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AZ D011897) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN122996) |
| 122300000X Dentist (Licence: MI 2901601197) | |
| Enumeration Date | 2022-05-17 |
| Last Update Date | 2023-08-09 |