| NPI | 1164051264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 38327) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 107400) |
| Enumeration Date | 2020-04-02 |
| Last Update Date | 2025-01-25 |