| NPI | 1821543810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CT 13031) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 151085) |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2022-03-28 |