| NPI | 1518105071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 24642) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2009-01-21 |
| Last Update Date | 2012-06-03 |