| NPI | 1114537602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 105153) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 39200) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 39200) | |
| Enumeration Date | 2020-08-09 |
| Last Update Date | 2023-02-03 |