NPI | 1669855607 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 32904) |
Additional Taxonomies | 122300000X Dentist (Licence: MA DL12619) |
Enumeration Date | 2015-07-08 |
Last Update Date | 2020-02-18 |