| NPI | 1063709848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 27131) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: OH 30-023395) |
| 1223P0300X Dentist, Periodontics (Licence: TX 27131) | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2024-02-19 |