| NPI | 1669996930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NY 062381) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13903) |
| 1223G0001X Dentist General Practice (Licence: MN D13903) | |
| 1223G0001X Dentist General Practice (Licence: TX 36835) | |
| Enumeration Date | 2017-07-28 |
| Last Update Date | 2023-03-31 |