| NPI | 1902056872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WI 6949) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8676) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TN DS9252) | |
| Enumeration Date | 2008-09-26 |
| Last Update Date | 2013-01-17 |