| NPI | 1336190099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 5948521-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 22989) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 22989) | |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2016-09-26 |