| NPI | 1235395880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: AZ D008508) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 23655) |
| 1223P0221X Dentist Pediatric Dentistry (Licence: UT 7788150-9922) | |
| Enumeration Date | 2008-08-04 |
| Last Update Date | 2013-03-29 |