| NPI | 1790149052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MD 9124) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: MD 9124) |
| Enumeration Date | 2016-04-12 |
| Last Update Date | 2016-04-12 |