| NPI | 1508144734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31733) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 15155) |
| 1223G0001X Dentist, General Practice (Licence: PA DS038795) | |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2020-12-16 |