| NPI | 1457825382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37716) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5250) |
| 1223G0001X Dentist, General Practice (Licence: NV 7138) | |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2021-08-16 |