| NPI | 1861695090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MO 2005034207) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 60711) |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2011-07-02 |