| NPI | 1295918092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 10425) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 23177) |
| Enumeration Date | 2007-12-14 |
| Last Update Date | 2015-12-30 |