| NPI | 1699014548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 39009) |
| Additional Taxonomies | 122300000X Dentist (Licence: ME FDN3) |
| Enumeration Date | 2013-02-12 |
| Last Update Date | 2022-09-19 |