| NPI | 1679986491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 31535) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 31535) |
| 122300000X Dentist (Licence: LA 6481) | |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2021-09-07 |