| NPI | 1679551048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32462) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 6161) |
| 1223G0001X Dentist, General Practice (Licence: CO 7596) | |
| Enumeration Date | 2006-01-05 |
| Last Update Date | 2018-07-20 |