| NPI | 1306165378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25425) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25425) |
| Enumeration Date | 2010-05-28 |
| Last Update Date | 2018-06-21 |