| NPI | 1104080605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 24301) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN17170) |
| Enumeration Date | 2008-07-14 |
| Last Update Date | 2017-11-09 |