| NPI | 1295099216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 83228799921) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6296) |
| Enumeration Date | 2012-06-25 |
| Last Update Date | 2022-05-24 |