| NPI | 1417182924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27439) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1855119) |
| Enumeration Date | 2009-05-28 |
| Last Update Date | 2012-04-18 |