| NPI | 1578776472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 3325 & Spec 501) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 7447) |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2013-03-01 |