| NPI | 1528315215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28644) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 61562) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2017-01-13 |