| NPI | 1346567542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25324) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 00000) |
| Enumeration Date | 2010-04-27 |
| Last Update Date | 2021-05-28 |