| NPI | 1174836803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25489) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 25489) |
| Enumeration Date | 2010-07-22 |
| Last Update Date | 2021-05-26 |