| NPI | 1073772687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25240) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 401413167) |
| 122300000X Dentist (Licence: KY 8605) | |
| Enumeration Date | 2008-06-09 |
| Last Update Date | 2020-05-12 |