| NPI | 1558675512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 31378) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: UT 7702857-9921) |
| Enumeration Date | 2010-08-02 |
| Last Update Date | 2017-06-30 |