| NPI | 1003541384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12943332-9941) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 38840) |
| Enumeration Date | 2022-07-20 |
| Last Update Date | 2023-05-30 |