| NPI | 1629055850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO DEN-9696) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 14053) |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2012-04-23 |