| NPI | 1619350840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35550) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1420) |
| Enumeration Date | 2015-07-07 |
| Last Update Date | 2021-01-11 |