| NPI | 1093042749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: TX 36845) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10039) |
| Enumeration Date | 2009-11-17 |
| Last Update Date | 2021-03-11 |