| NPI | 1821628900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 38093) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA DDS103136) |
| Enumeration Date | 2020-01-17 |
| Last Update Date | 2022-01-30 |