| NPI | 1174611636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25173) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 6316077) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2011-06-06 |