| NPI | 1376646448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 23795) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS018023L) |
| Enumeration Date | 2006-09-06 |
| Last Update Date | 2014-04-11 |