| NPI | 1467989921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: PA DS040396) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040396) |
| Enumeration Date | 2017-05-16 |
| Last Update Date | 2017-10-16 |