| NPI | 1043763329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32014) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 32014) |
| Enumeration Date | 2016-08-03 |
| Last Update Date | 2019-05-13 |