| NPI | 1063533297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27505) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 3220) |
| Enumeration Date | 2007-04-03 |
| Last Update Date | 2020-11-03 |