| NPI | 1144750902 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 12294438-9922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 32963) |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2023-01-26 |