| NPI | 1265871859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4661) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 28927) |
| Enumeration Date | 2013-06-18 |
| Last Update Date | 2017-04-18 |