| NPI | 1417395666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 30613) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8687603-9922) |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2021-01-05 |