| NPI | 1932198801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: SC 0657) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 4227) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2008-04-15 |