| NPI | 1497129787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: VA 0401415033) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415033) |
| Enumeration Date | 2015-11-24 |
| Last Update Date | 2018-07-25 |