| NPI | 1306965736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 19706) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM 2385) |
| Enumeration Date | 2007-03-28 |
| Last Update Date | 2024-11-26 |