| NPI | 1124470471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34866) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100362) |
| Enumeration Date | 2016-07-11 |
| Last Update Date | 2020-07-15 |