| NPI | 1235417767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27239) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 27239) |
| Enumeration Date | 2011-08-02 |
| Last Update Date | 2022-07-21 |