| NPI | 1003262098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32132) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 32132) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-05-09 |
| Last Update Date | 2018-09-26 |