| NPI | 1366460693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 21470) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2023-08-02 |