| NPI | 1417012709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30867) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PR 1945) |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2020-04-07 |