| NPI | 1154815058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO 00204172) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 34001) |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2021-09-14 |