| NPI | 1134623523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 103762) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 33792) |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2021-12-13 |