| NPI | 1487749669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401004793) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401004793) |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2007-07-09 |