| NPI | 1568555654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 23585) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: PA DS031122L) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2022-06-30 |