| NPI | 1285890368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 57254) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24145) |
| 1223G0001X Dentist, General Practice (Licence: NV 5779) | |
| 1223G0001X Dentist, General Practice (Licence: TX 24145) | |
| Enumeration Date | 2008-07-29 |
| Last Update Date | 2022-01-12 |