| NPI | 1457420705 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27804) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NC NC107695) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2023-07-07 |