| NPI | 1295214567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TX 37148) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 37148) |
| Enumeration Date | 2018-08-08 |
| Last Update Date | 2023-08-20 |