| NPI | 1194971382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 28375) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 10201) |
| Enumeration Date | 2008-08-07 |
| Last Update Date | 2013-12-03 |