| NPI | 1073243036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 38503) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 38503) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2026-05-22 |