| NPI | 1508283961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 32504) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62643) |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2018-07-10 |