| NPI | 1104158146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28787) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 59123) |
| Enumeration Date | 2010-02-01 |
| Last Update Date | 2022-03-21 |