| NPI | 1942463393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: AZ D07640) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MA 10125) |
| Enumeration Date | 2008-07-07 |
| Last Update Date | 2015-12-29 |