| NPI | 1255480208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 204434) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 4970) |
| 1223G0001X Dentist, General Practice (Licence: TX 24431) | |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2023-06-07 |