| NPI | 1285653626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MD 10440) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 16170) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2007-09-26 |