| NPI | 1568766624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 0026091) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0026091) |
| Enumeration Date | 2011-01-04 |
| Last Update Date | 2012-11-29 |