| NPI | 1386027357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202692) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 30816) |
| Enumeration Date | 2015-07-08 |
| Last Update Date | 2018-01-11 |