| NPI | 1720078058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00000167) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: CO 0167) |
| Enumeration Date | 2005-10-27 |
| Last Update Date | 2021-07-28 |