| NPI | 1588763528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO 9143) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: CO 9143) |
| 1223P0300X Dentist, Periodontics (Licence: UT 53318729922) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 53318729922) | |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2010-05-13 |