| NPI | 1619319662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 33709) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15487) |
| Enumeration Date | 2013-07-18 |
| Last Update Date | 2021-01-11 |