| NPI | 1154758597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30902) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: DC DEN1001309) |
| Enumeration Date | 2013-09-30 |
| Last Update Date | 2015-08-14 |