| NPI | 1386406999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 14231492-9926) |
| Additional Taxonomies | 261QS1000X Clinic/Center, Student Health |
| Enumeration Date | 2024-01-29 |
| Last Update Date | 2025-07-22 |