| NPI | 1083875892 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 24055) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0024055) |
| 1223G0001X Dentist, General Practice (Licence: TX 0024055) | |
| Enumeration Date | 2008-06-24 |
| Last Update Date | 2022-10-27 |