| NPI | 1205115235 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID D4596) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 0027151) |
| Enumeration Date | 2011-08-08 |
| Last Update Date | 2024-02-20 |