| NPI | 1487968459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00201903) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25839) |
| Enumeration Date | 2010-08-03 |
| Last Update Date | 2014-09-12 |