| NPI | 1578879417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: CO 10630) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6068) |
| Enumeration Date | 2010-08-30 |
| Last Update Date | 2023-09-12 |