| NPI | 1558745224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31134) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 11664262) |
| Enumeration Date | 2015-07-13 |
| Last Update Date | 2024-10-14 |