| NPI | 1194869420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 8066) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 8066) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 32699) | |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2019-07-09 |