NPI | 1487657193 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | |
Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: OH 13887) |
Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 369) |
Enumeration Date | 2005-05-27 |
Last Update Date | 2007-07-08 |