| NPI | 1730595802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN015099) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 1302) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2022-03-08 |