| NPI | 1265630677 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28558) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AR 3907) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: WV 3716) | |
| Enumeration Date | 2007-07-06 |
| Last Update Date | 2018-03-17 |