| NPI | 1467788646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR d10741) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24549) |
| 122300000X Dentist (Licence: CA 105196) | |
| Enumeration Date | 2009-10-23 |
| Last Update Date | 2023-09-29 |