| NPI | 1134205594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 20716) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 20716) |
| Enumeration Date | 2006-10-28 |
| Last Update Date | 2022-01-21 |