| NPI | 1215244330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 25953) |
| Additional Taxonomies | 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: TX 25953) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2011-01-18 |