| NPI | 1205191533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34658) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS039396) |
| 1223G0001X Dentist, General Practice (Licence: IL 019029165) | |
| 1223G0001X Dentist, General Practice (Licence: WI 7003-15) | |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2019-11-16 |