| NPI | 1821508359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CO 203820) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: NE 149) |
| 122300000X Dentist (Licence: NE 149) | |
| Enumeration Date | 2017-10-11 |
| Last Update Date | 2025-01-29 |