| NPI | 1215486139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 205864) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32406) |
| Enumeration Date | 2016-10-04 |
| Last Update Date | 2025-03-10 |