| NPI | 1639428634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OR D10379) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE 60278162) |
| Enumeration Date | 2012-09-05 |
| Last Update Date | 2019-04-29 |