| NPI | 1174929707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33650) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 9137998-9921) |
| Enumeration Date | 2014-11-10 |
| Last Update Date | 2019-10-21 |