| NPI | 1629003835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 17470) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 0410271) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401008137) | |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2007-07-08 |