| NPI | 1417843269 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DB-2025-0193) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 41522) |
| 122300000X Dentist (Licence: CA 112223) | |
| Enumeration Date | 2025-06-17 |
| Last Update Date | 2025-08-25 |