| NPI | 1215285861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28167) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28167) |
| Enumeration Date | 2012-08-29 |
| Last Update Date | 2022-01-28 |