| NPI | 1215379540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 8490378-9922) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: NE 112) |
| Enumeration Date | 2013-07-29 |
| Last Update Date | 2014-06-11 |