| NPI | 1053745927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 29690) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50 056913) |
| Enumeration Date | 2013-08-28 |
| Last Update Date | 2021-01-11 |