| NPI | 1356636229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27047) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00201947) |
| Enumeration Date | 2011-06-18 |
| Last Update Date | 2022-09-23 |