| NPI | 1790901015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VT 016.0077184) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 14168) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: NH 04022) | |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2014-05-03 |