| NPI | 1558476705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 25835) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019030) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NM DD3357) | |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2013-05-29 |