| NPI | 1568848463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60765460) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MA DL12655) |
| Enumeration Date | 2015-08-03 |
| Last Update Date | 2019-01-31 |