| NPI | 1710085360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: SC 681) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 4287) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2012-11-13 |