| NPI | 1083161665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 11672604-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32124) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2020-05-07 |