| NPI | 1063815975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: WI 17972-875) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: TX 27418) |
| Enumeration Date | 2014-10-06 |
| Last Update Date | 2015-07-26 |