| NPI | 1114346301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33543) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33543) |
| 1223G0001X Dentist, General Practice (Licence: GA DN014748) | |
| Enumeration Date | 2014-04-15 |
| Last Update Date | 2019-07-23 |