| NPI | 1003149287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24993) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24993) |
| Enumeration Date | 2009-09-07 |
| Last Update Date | 2016-11-30 |