| NPI | 1194164095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 29659) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039579) |
| 122300000X Dentist (Licence: TX 29659) | |
| 1223G0001X Dentist General Practice (Licence: PA DS039579) | |
| Enumeration Date | 2013-06-24 |
| Last Update Date | 2016-11-02 |