| NPI | 1639268907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25259) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D8231) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2014-09-05 |