| NPI | 1487086583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401419261) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039683) |
| Enumeration Date | 2013-07-31 |
| Last Update Date | 2025-05-07 |