| NPI | 1114333903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 36187) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 0977) |
| 122300000X Dentist (Licence: FL 20642) | |
| 1223G0001X Dentist, General Practice (Licence: OH 30.025952) | |
| Enumeration Date | 2014-07-01 |
| Last Update Date | 2021-06-11 |