| NPI | 1518341320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 36347) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1857183) |
| Enumeration Date | 2015-07-13 |
| Last Update Date | 2021-12-19 |