| NPI | 1093795122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 122300000X Dentist (Licence: MO DE014689) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MO DE014689) |
| 1223G0001X Dentist General Practice (Licence: TX 17588) | |
| 122300000X Dentist (Licence: TX 17588) | |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2007-07-08 |