| NPI | 1316922164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: UT 11779981) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 7575) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2022-07-21 |