| NPI | 1114118601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25159) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 6605192) |
| Enumeration Date | 2007-08-08 |
| Last Update Date | 2025-01-27 |