| NPI | 1407941065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: TX 18252) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: LA 4443) |
| 204E00000X Oral & Maxillofacial Surgery (Licence: TX 18252) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2009-09-13 |