| NPI | 1336586460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32782) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00206402) |
| Enumeration Date | 2013-05-30 |
| Last Update Date | 2025-11-20 |