| NPI | 1033595574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 38234) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60699876) |
| 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) | |
| Enumeration Date | 2015-08-06 |
| Last Update Date | 2023-11-06 |