| NPI | 1376975680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: UT 8726975-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8726975-9922) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 39234) | |
| Enumeration Date | 2013-08-09 |
| Last Update Date | 2025-01-30 |