| NPI | 1477539435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 21280) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 053285) |
| 122300000X Dentist (Licence: TX 21280) | |
| Enumeration Date | 2005-12-21 |
| Last Update Date | 2010-07-14 |