| NPI | 1013006345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 19593) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 19593) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2019-06-11 |