| NPI | 1982830923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 28910) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D12670) |
| Enumeration Date | 2009-06-04 |
| Last Update Date | 2018-03-17 |