| NPI | 1174053078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 7695) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV LL-548-21) |
| 1223G0001X Dentist, General Practice (Licence: CA 101397) | |
| 1223G0001X Dentist, General Practice (Licence: TX 33969) | |
| Enumeration Date | 2017-06-14 |
| Last Update Date | 2024-03-05 |