| NPI | 1649811746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 12611) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AL 0006706) |
| Enumeration Date | 2019-10-01 |
| Last Update Date | 2022-08-23 |