| NPI | 1043296312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 15889) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD2225) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2012-01-03 |