| NPI | 1467940965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35802) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 10800699-8903) |
| 1223G0001X Dentist, General Practice (Licence: UT 10800699-9922) | |
| Enumeration Date | 2018-04-30 |
| Last Update Date | 2019-12-16 |