| NPI | 1104086735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 25175) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25175) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: PA 00000000000000000000) | |
| Enumeration Date | 2008-06-17 |
| Last Update Date | 2024-07-05 |