| NPI | 1275932964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: TX 33346) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DRP #1173) |
| Enumeration Date | 2014-08-19 |
| Last Update Date | 2021-02-18 |