| NPI | 1790776920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 6671559-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D12090) |
| Enumeration Date | 2005-11-05 |
| Last Update Date | 2008-12-31 |