| NPI | 1538509542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: FL DN21701) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039613) |
| Enumeration Date | 2013-07-05 |
| Last Update Date | 2025-12-08 |