| NPI | 1265501720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 205319) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 14945) |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2022-11-03 |