| NPI | 1851708796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 6013345-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00202242) |
| Enumeration Date | 2014-07-11 |
| Last Update Date | 2018-11-21 |