| NPI | 1598976433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25724) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8403) |
| 122300000X Dentist (Licence: CA 55745) | |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2014-08-15 |