| NPI | 1154094159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 13427199-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 37309) |
| Enumeration Date | 2021-07-27 |
| Last Update Date | 2023-08-07 |