| NPI | 1669076188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 13153333-9926) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00204518) |
| Enumeration Date | 2020-11-24 |
| Last Update Date | 2024-09-16 |