| NPI | 1558523860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 26332) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 5683) |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2019-09-29 |