| NPI | 1407045735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 24289) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24289) |
| 122300000X Dentist (Licence: MN D12360) | |
| Enumeration Date | 2007-10-23 |
| Last Update Date | 2020-07-01 |