| NPI | 1053532606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 27494) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 5346802-9921) |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2019-06-25 |