| NPI | 1447538400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX TX28527) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD3548) |
| Enumeration Date | 2011-07-25 |
| Last Update Date | 2021-03-03 |