| NPI | 1407297484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: TN 11869) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203425) |
| 1223G0001X Dentist General Practice (Licence: TX 31790) | |
| 1223G0001X Dentist General Practice (Licence: CA 62475) | |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2023-03-24 |