| NPI | 1518034511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OH 21455) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9125) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2015-01-20 |