| NPI | 1821631516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 9687) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 8990) |
| Enumeration Date | 2019-10-24 |
| Last Update Date | 2022-08-10 |