| NPI | 1780002964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AZ D009844) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CO DEN.00202669) |
| Enumeration Date | 2014-04-03 |
| Last Update Date | 2022-07-02 |