| NPI | 1578116968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 35480) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401416654) |
| Enumeration Date | 2019-07-24 |
| Last Update Date | 2021-04-02 |