| NPI | 1356458053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 55982419921) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: UT 5598421-4701) |
| 122300000X Dentist (Licence: AZ D 5888) | |
| 122300000X Dentist (Licence: UT 5598241-9921) | |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2021-11-17 |