| NPI | 1720241417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 8569) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8569) |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2020-02-05 |