| NPI | 1568914851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN015279) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015279) |
| Enumeration Date | 2016-11-02 |
| Last Update Date | 2021-01-24 |