| NPI | 1265552368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 14684) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 5965) |
| 122300000X Dentist (Licence: NM 1514) | |
| Enumeration Date | 2007-03-30 |
| Last Update Date | 2007-07-08 |