| NPI | 1265477095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 14890) |
| Additional Taxonomies | 1223D0004X Dentist Dentist Anesthesiologist (Licence: TX 14890) |
| Enumeration Date | 2006-06-17 |
| Last Update Date | 2013-05-29 |