| NPI | 1154676575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 28018) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28018) |
| Enumeration Date | 2012-07-23 |
| Last Update Date | 2023-10-27 |