| NPI | 1548547425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO DEN.00203854) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413384) |
| Enumeration Date | 2011-11-07 |
| Last Update Date | 2023-12-06 |