| NPI | 1669602777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D9739) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 745) |
| 122300000X Dentist (Licence: UT 7983955-9923) | |
| Enumeration Date | 2009-07-23 |
| Last Update Date | 2013-02-10 |