| NPI | 1396289419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32585) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401415461) |
| 1223G0001X Dentist General Practice (Licence: TX 32585) | |
| Enumeration Date | 2016-12-08 |
| Last Update Date | 2022-12-27 |