| NPI | 1093963357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 24193) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24193) |
| 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: TX 24193) | |
| Enumeration Date | 2008-08-28 |
| Last Update Date | 2013-03-28 |