| NPI | 1740525096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 29591) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6178) |
| Enumeration Date | 2012-11-27 |
| Last Update Date | 2016-10-14 |