| NPI | 1649416157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 24591) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 71786569922) |
| Enumeration Date | 2009-01-05 |
| Last Update Date | 2010-05-06 |