| NPI | 1548459662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 21396) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 55851) |
| Enumeration Date | 2007-10-15 |
| Last Update Date | 2012-10-08 |