| NPI | 1770149742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 0401415613) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: VA 0401415613) |
| Enumeration Date | 2019-05-15 |
| Last Update Date | 2020-02-10 |