| NPI | 1700309291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 39467) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ME 4582) |
| Enumeration Date | 2017-07-17 |
| Last Update Date | 2024-06-17 |