| NPI | 1427326875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27750) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| 122300000X Dentist (Licence: CA 60959) | |
| Enumeration Date | 2011-12-13 |
| Last Update Date | 2020-09-16 |