| NPI | 1508940545 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: SD D0826) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D10782) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2014-05-07 |