| NPI | 1548632607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CT 12130) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 65151) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 65151) | |
| Enumeration Date | 2015-10-28 |
| Last Update Date | 2018-03-17 |