| NPI | 1558611087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28268) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28628) |
| Enumeration Date | 2012-09-12 |
| Last Update Date | 2021-06-17 |