| NPI | 1154586170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4194) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0024099) |
| 122300000X Dentist (Licence: NY 053883) | |
| Enumeration Date | 2008-07-21 |
| Last Update Date | 2021-04-08 |