| NPI | 1679949374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 31140) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 31140) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: NC 11842) | |
| Enumeration Date | 2015-08-17 |
| Last Update Date | 2022-04-07 |