| NPI | 1073504171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD1812) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 14923) |
| Enumeration Date | 2005-10-30 |
| Last Update Date | 2007-07-08 |