| NPI | 1063763167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D9882) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX ETN377) |
| Enumeration Date | 2012-09-28 |
| Last Update Date | 2019-02-22 |