| NPI | 1285919860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27280) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 60459) |
| Enumeration Date | 2011-10-14 |
| Last Update Date | 2011-10-14 |