| NPI | 1659369700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 50156499924) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD2287) |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2023-07-05 |