| NPI | 1265773675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 33552) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 057883) |
| Enumeration Date | 2013-03-11 |
| Last Update Date | 2019-10-02 |