| NPI | 1831236892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010566) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D3933) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 140755 9921) | |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2020-04-16 |