| NPI | 1649523648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 29306) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 2911) |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2018-03-14 |