| NPI | 1588645006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8031) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 8031) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 8031) | |
| Enumeration Date | 2005-11-10 |
| Last Update Date | 2023-01-26 |