| NPI | 1497019640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: NC 09693) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 1086) |
| 1223P0221X Dentist Pediatric Dentistry (Licence: GA DN014976) | |
| Enumeration Date | 2012-07-02 |
| Last Update Date | 2019-03-19 |