| NPI | 1114215902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 31685) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 60493) |
| Enumeration Date | 2011-07-14 |
| Last Update Date | 2018-10-12 |