| NPI | 1649424029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: UT 5114556) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: UT 5114556) |
| Enumeration Date | 2008-11-11 |
| Last Update Date | 2013-07-17 |