| NPI | 1184036410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 9033355) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: UT 9033355) |
| Enumeration Date | 2014-05-21 |
| Last Update Date | 2025-02-11 |