| NPI | 1134493638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27721) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 27721) |
| Enumeration Date | 2012-03-01 |
| Last Update Date | 2012-12-18 |