| NPI | 1740479252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CO 9021) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 9021) |
| 1223P0300X Dentist, Periodontics (Licence: CO 9021) | |
| Enumeration Date | 2007-10-20 |
| Last Update Date | 2009-09-22 |