| NPI | 1770893414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OK 6912) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10313) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WY 1329) | |
| Enumeration Date | 2010-10-15 |
| Last Update Date | 2022-07-21 |