| NPI | 1649545211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401417359) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5001) |
| 1223G0001X Dentist, General Practice (Licence: CO 10645) | |
| Enumeration Date | 2012-03-15 |
| Last Update Date | 2021-04-07 |