| NPI | 1508931270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 34941) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 19937) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2020-01-14 |