| NPI | 1902966898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ 3317) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AZ 3317) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2019-04-15 |