| NPI | 1720447865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60752640) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 059985) |
| Enumeration Date | 2016-02-17 |
| Last Update Date | 2020-07-24 |