| NPI | 1659712578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: GA DN014605) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN014605) |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2023-03-15 |