| NPI | 1376825059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4069) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 28192) |
| Enumeration Date | 2011-09-19 |
| Last Update Date | 2016-10-14 |