| NPI | 1699895524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NE 6226) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: NE 6226) |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2023-09-05 |