| NPI | 1518019512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 28516) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA 11589) |
| Enumeration Date | 2007-01-18 |
| Last Update Date | 2022-07-21 |