| NPI | 1548232580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PR 2036) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: PR 2036) |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2020-07-13 |