| NPI | 1104987478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 15907) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: TX 15907) |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2022-06-15 |