| NPI | 1154619088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 27129) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27129) |
| Enumeration Date | 2011-07-12 |
| Last Update Date | 2021-06-30 |