| NPI | 1659575207 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 63513) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 19750) |
| 1223G0001X Dentist, General Practice (Licence: TX 19750) | |
| 1223G0001X Dentist, General Practice (Licence: CA 63513) | |
| Enumeration Date | 2007-06-14 |
| Last Update Date | 2015-03-11 |