| NPI | 1619289238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO 00205320) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412894) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: NM D3745) | |
| Enumeration Date | 2010-07-12 |
| Last Update Date | 2025-03-25 |