| NPI | 1861918567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 36132) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13908) |
| Enumeration Date | 2017-08-15 |
| Last Update Date | 2023-11-08 |