| NPI | 1124546809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO DEN.00203228) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: TX 36105) |
| Enumeration Date | 2017-09-01 |
| Last Update Date | 2020-07-01 |