| NPI | 1306083431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24268) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24268) |
| Enumeration Date | 2009-01-12 |
| Last Update Date | 2012-09-10 |