| NPI | 1104874346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 17774) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD1255) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2016-06-07 |