| NPI | 1588893622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AL 3102) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AL AL3102) |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2012-07-31 |