| NPI | 1174870547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: CO 00204233) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28212) |
| Enumeration Date | 2012-08-05 |
| Last Update Date | 2023-08-07 |