| NPI | 1558382812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 57104) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: RI 02897) |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MA 20950) | |
| Enumeration Date | 2006-07-22 |
| Last Update Date | 2010-03-04 |