| NPI | 1609896851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SD D1177) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-3996) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: WY 1308) | |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2020-08-31 |