| NPI | 1003815614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD2568) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 16841) |
| Enumeration Date | 2005-07-15 |
| Last Update Date | 2025-10-09 |