| NPI | 1821638883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PA DS042388) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS042388) |
| Enumeration Date | 2020-01-08 |
| Last Update Date | 2025-04-10 |