| NPI | 1679993729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D10750) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040182) |
| Enumeration Date | 2014-04-16 |
| Last Update Date | 2019-09-04 |