| NPI | 1649626961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31631) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 31631) |
| 1223G0001X Dentist General Practice (Licence: KY 9545) | |
| Enumeration Date | 2016-05-05 |
| Last Update Date | 2022-02-04 |