| NPI | 1639477417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 30847) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: UT 8023152-9921) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-03-03 |
| Last Update Date | 2020-10-02 |