| NPI | 1124236674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30578) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 049594) |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2016-08-23 |