| NPI | 1194708438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24362) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 4441) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2021-07-07 |