| NPI | 1689891277 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 717) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 3659) |
| Enumeration Date | 2007-04-18 |
| Last Update Date | 2013-09-27 |