| NPI | 1134103005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25911) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25911) |
| 122300000X Dentist (Licence: TX 25911) | |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2026-02-19 |