| NPI | 1679973697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 30609) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN20921) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: FL DN20921) | |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: KS 62261) | |
| Enumeration Date | 2014-08-27 |
| Last Update Date | 2026-03-23 |