| NPI | 1619947967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35085) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 048871) |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2020-12-21 |