| NPI | 1629070784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 28760) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9306) |
| 1223G0001X Dentist, General Practice (Licence: MI 016394) | |
| Enumeration Date | 2005-06-02 |
| Last Update Date | 2013-06-10 |