| NPI | 1114543121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 37175) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK RES1363) |
| 122300000X Dentist (Licence: TX 37175) | |
| Enumeration Date | 2020-06-25 |
| Last Update Date | 2023-10-18 |