| NPI | 1619106606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25277) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 58392) |
| 122300000X Dentist (Licence: TX 25277) | |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2021-06-02 |