| NPI | 1962934612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NM DD4663) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD0000) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NM DD0000) | |
| Enumeration Date | 2017-03-31 |
| Last Update Date | 2019-07-19 |