| NPI | 1164785952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: TX 29874) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15076) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2016-05-17 |