| NPI | 1871883140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 14861) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 14861) |
| Enumeration Date | 2011-04-07 |
| Last Update Date | 2025-01-13 |