| NPI | 1720092984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS022416L) |
| Additional Taxonomies | 174400000X Specialist (Licence: PA DS022416L) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2015-12-15 |