| NPI | 1619022969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 348627) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 348627-9922) |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2020-10-13 |