| NPI | 1497867519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: IA 08297) |
| Additional Taxonomies | 1223G0001X Dentist General Practice |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2007-07-08 |