| NPI | 1912115056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: GA 9074) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: GA 9074) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2007-07-09 |