| NPI | 1578636080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28799) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 5059) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2021-02-24 |