| NPI | 1497365662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 36479) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD5306) |
| Enumeration Date | 2020-08-03 |
| Last Update Date | 2021-05-25 |