| NPI | 1902092075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MD 13390) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401411070) |
| 122300000X Dentist (Licence: DC den1000523) | |
| Enumeration Date | 2007-09-21 |
| Last Update Date | 2022-08-25 |