| NPI | 1003845322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24384) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 21345) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2011-09-19 |