| NPI | 1063918548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: TX 38194) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 102711) |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2022-12-22 |