| NPI | 1225414345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33946) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID 4689) |
| Enumeration Date | 2015-07-31 |
| Last Update Date | 2023-10-03 |