| NPI | 1811091358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: FL DN23270) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8161) |
| Enumeration Date | 2006-09-12 |
| Last Update Date | 2019-01-03 |