| NPI | 1417416728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist Orofacial Pain (Licence: TX 35081) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 35081) |
| 1223G0001X Dentist General Practice (Licence: WA 60795714) | |
| 1223G0001X Dentist General Practice (Licence: TX 35081) | |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 35081) | |
| Enumeration Date | 2019-03-16 |
| Last Update Date | 2023-01-09 |