| NPI | 1154878700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 32295) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 100675) |
| 1223G0001X Dentist, General Practice (Licence: MA 1858246) | |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2021-09-13 |