| NPI | 1568611275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24716) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY P65190) |
| Enumeration Date | 2008-09-17 |
| Last Update Date | 2010-10-14 |