| NPI | 1396737557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: NM DD2445) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 8306) |
| 1223P0221X Dentist Pediatric Dentistry (Licence: TX 25762) | |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2013-10-29 |