| NPI | 1336589951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4236) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 29647) |
| 1223G0001X Dentist, General Practice (Licence: PA DS039583) | |
| Enumeration Date | 2013-06-27 |
| Last Update Date | 2018-06-27 |