| NPI | 1003104886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27219) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 09184) |
| 122300000X Dentist (Licence: PA 040428) | |
| 1223P0221X Dentist Pediatric Dentistry (Licence: MD LL900) | |
| Enumeration Date | 2011-07-14 |
| Last Update Date | 2024-07-10 |