| NPI | 1457494809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 18403) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 5983) |
| 1223D0001X Dentist, Dental Public Health (Licence: TX 18403) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2007-07-08 |