| NPI | 1528542073 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 38096) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NC 151224) |
| Enumeration Date | 2018-09-20 |
| Last Update Date | 2022-07-16 |