| NPI | 1215551106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: UT 11797305-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 11797305-9921) |
| Enumeration Date | 2020-06-05 |
| Last Update Date | 2023-08-19 |