| NPI | 1013572247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD5100) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 35126) |
| Enumeration Date | 2019-05-02 |
| Last Update Date | 2019-06-15 |