| NPI | 1073708343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 5062) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 22901) |
| 122300000X Dentist (Licence: NY 53391) | |
| Enumeration Date | 2007-09-10 |
| Last Update Date | 2009-07-23 |