| NPI | 1750512703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 7729107) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NV LL-201-09) |
| Enumeration Date | 2009-08-06 |
| Last Update Date | 2012-11-13 |