| NPI | 1376600155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25211) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D3200) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2015-07-15 |