| NPI | 1245421205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 22263) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 22263) |
| 1223G0001X Dentist General Practice (Licence: TX 22263) | |
| Enumeration Date | 2007-08-06 |
| Last Update Date | 2009-04-11 |