| NPI | 1588031074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 31419) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1857463) |
| Enumeration Date | 2015-08-31 |
| Last Update Date | 2025-09-25 |