| NPI | 1588851752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 23188) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 55479) |
| Enumeration Date | 2007-10-01 |
| Last Update Date | 2020-12-17 |