| NPI | 1770711558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 31666) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: NH 03987) |
| 1223P0221X Dentist Pediatric Dentistry (Licence: MA DN1856248) | |
| Enumeration Date | 2009-06-30 |
| Last Update Date | 2021-04-16 |