| NPI | 1114560927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 39205) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 104005) |
| 122300000X Dentist (Licence: NV 7963) | |
| Enumeration Date | 2019-10-24 |
| Last Update Date | 2024-07-09 |