| NPI | 1104499698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37543) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 7436) |
| Enumeration Date | 2021-07-21 |
| Last Update Date | 2023-03-01 |