| NPI | 1811336142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: MD 15309) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MD 15309) |
| Enumeration Date | 2013-06-20 |
| Last Update Date | 2019-10-09 |