| NPI | 1790826493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN013840) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 5891) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401007761) | |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2016-03-09 |