| NPI | 1730650037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 34611) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 34611) |
| 122300000X Dentist (Licence: NE 157) | |
| Enumeration Date | 2018-12-12 |
| Last Update Date | 2021-01-05 |