| NPI | 1316317696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33169) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 9489417) |
| Enumeration Date | 2015-09-30 |
| Last Update Date | 2019-12-30 |