| NPI | 1679066526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 36292) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10145) |
| 122300000X Dentist (Licence: FL 23568) | |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2021-06-28 |