| NPI | 1639609811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00203349) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10877277-9921) |
| 122300000X Dentist (Licence: AZ D010623) | |
| 1223G0001X Dentist, General Practice (Licence: TX 33029) | |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2023-04-22 |