| NPI | 1871931394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: UT 4915094-9921) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 9308) |
| Enumeration Date | 2013-06-06 |
| Last Update Date | 2023-04-05 |