| NPI | 1316972805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 22926) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 049439) |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2015-02-02 |