| NPI | 1720548787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN S239) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 112057379921) |
| Enumeration Date | 2019-03-24 |
| Last Update Date | 2025-07-10 |