| NPI | 1154761393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 29540) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 29540) |
| 122300000X Dentist (Licence: PA DS039642) | |
| Enumeration Date | 2013-07-02 |
| Last Update Date | 2013-11-19 |