| NPI | 1063860344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 31885) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415216) |
| 122300000X Dentist (Licence: TX 31885) | |
| 1223P0300X Dentist, Periodontics (Licence: TX 31885) | |
| Enumeration Date | 2016-05-27 |
| Last Update Date | 2023-09-20 |