| NPI | 1649686189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 32046) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 058930) |
| Enumeration Date | 2014-07-04 |
| Last Update Date | 2017-03-17 |