| NPI | 1780255679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: VA 0401416797) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401416797) |
| Enumeration Date | 2021-07-02 |
| Last Update Date | 2022-04-20 |