| NPI | 1093815706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ 7249) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25162) |
| 122300000X Dentist (Licence: NC 9075) | |
| Enumeration Date | 2006-09-23 |
| Last Update Date | 2012-05-31 |