| NPI | 1063406734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27515) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 6602) |
| Enumeration Date | 2005-09-08 |
| Last Update Date | 2016-08-08 |