| NPI | 1295179927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28829) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62316) |
| Enumeration Date | 2013-04-24 |
| Last Update Date | 2014-10-08 |