| NPI | 1992967079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NC 10446) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: FL DN18441) |
| Enumeration Date | 2008-06-30 |
| Last Update Date | 2022-07-21 |