| NPI | 1780161646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 0442000332) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: VA 0442000332) |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2021-08-17 |