| NPI | 1548855851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NC 13535) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 10651) |
| Enumeration Date | 2021-03-08 |
| Last Update Date | 2023-12-19 |