| NPI | 1124003827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 28942) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 5341) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2018-01-25 |