| NPI | 1104118520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27843) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 60154) |
| Enumeration Date | 2011-05-03 |
| Last Update Date | 2018-07-18 |