| NPI | 1649639295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: IA 09962) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MO 2018015588) |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2022-03-27 |