| NPI | 1801269261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR 10452) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00202440) |
| Enumeration Date | 2015-11-06 |
| Last Update Date | 2016-08-20 |