| NPI | 1841648524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 10480) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 10297) |
| 122300000X Dentist (Licence: NC 10380) | |
| 122300000X Dentist (Licence: NY 060991) | |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2023-05-18 |