| NPI | 1639596463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: TX 33738) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33738) |
| 122300000X Dentist (Licence: PR 3165) | |
| Enumeration Date | 2014-03-18 |
| Last Update Date | 2026-08-23 |