| NPI | 1467749291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 8012613-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27972) |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2012-09-19 |