| NPI | 1568665289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 22806) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 150548) |
| Enumeration Date | 2007-06-08 |
| Last Update Date | 2011-08-16 |