| NPI | 1205385523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: TX 1179135) |
| Additional Taxonomies | 126800000X Dental Assistant (Licence: TX 35773) |
| Enumeration Date | 2016-09-28 |
| Last Update Date | 2025-05-22 |