| NPI | 1225699945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 36862) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1530) |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2020-11-24 |