| NPI | 1962810929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: PA DS041174) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 30313) |
| Enumeration Date | 2014-07-22 |
| Last Update Date | 2021-04-06 |