| NPI | 1093035966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 25482) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0025482) |
| Enumeration Date | 2010-06-02 |
| Last Update Date | 2020-04-08 |