NPI | 1093075830 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 28094) |
Additional Taxonomies | 122300000X Dentist (Licence: TX 28094) |
390200000X Student in an Organized Health Care Education/Training Program | |
Enumeration Date | 2012-05-28 |
Last Update Date | 2018-12-18 |