| NPI | 1417228032 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 8705196) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 27130) |
| Enumeration Date | 2012-01-13 |
| Last Update Date | 2014-03-31 |