| NPI | 1558599761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28772) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D2950) |
| Enumeration Date | 2009-06-25 |
| Last Update Date | 2022-09-08 |