| NPI | 1700159266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ZZ 1403391) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: ZZ AE-008082) |
| Enumeration Date | 2012-02-14 |
| Last Update Date | 2012-02-14 |