| NPI | 1679345698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 40128) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 40128) |
| Enumeration Date | 2023-10-23 |
| Last Update Date | 2023-12-14 |