| NPI | 1366739286 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27124) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27124) |
| Enumeration Date | 2011-06-29 |
| Last Update Date | 2024-06-11 |