| NPI | 1629275151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: UT 141853-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 141853-9921) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 141853) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 141853) | |
| Enumeration Date | 2007-06-28 |
| Last Update Date | 2021-12-20 |