| NPI | 1750630646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MD 15292) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15292) |
| Enumeration Date | 2012-09-06 |
| Last Update Date | 2015-07-22 |