| NPI | 1548820566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00204949) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD5111) |
| 122300000X Dentist (Licence: TX 35155) | |
| Enumeration Date | 2019-06-20 |
| Last Update Date | 2023-08-11 |