| NPI | 1164770004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31169) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8375200-9922) |
| 122300000X Dentist (Licence: UT 8375200-8903) | |
| Enumeration Date | 2012-08-27 |
| Last Update Date | 2016-10-18 |