| NPI | 1508070582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 15172) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 122300000X) |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2020-11-12 |