| NPI | 1548642457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 31862) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9447446) |
| Enumeration Date | 2015-06-27 |
| Last Update Date | 2021-01-11 |