| NPI | 1588049233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 10757585-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15995) |
| Enumeration Date | 2015-07-23 |
| Last Update Date | 2018-05-22 |