| NPI | 1821167495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: WV 60) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV 2275) |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2012-12-06 |