| NPI | 1174193213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37540) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D14617) |
| Enumeration Date | 2021-06-30 |
| Last Update Date | 2023-05-18 |