| NPI | 1245837152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 36795) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1858846) |
| Enumeration Date | 2020-10-04 |
| Last Update Date | 2022-06-21 |