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 |