| NPI | 1508852260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WI 5076) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 5076-015) |
| Enumeration Date | 2005-09-27 |
| Last Update Date | 2015-10-28 |