| NPI | 1003441890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35774) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 35774) |
| Enumeration Date | 2020-03-11 |
| Last Update Date | 2021-01-11 |