| NPI | 1639380595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 15470) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 15470) |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2017-10-23 |