| NPI | 1336458397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WY 1457) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25993) |
| Enumeration Date | 2010-09-24 |
| Last Update Date | 2016-09-22 |