| NPI | 1689934812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 36915) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6895) |
| 122300000X Dentist (Licence: MI 2901020648) | |
| 122300000X Dentist (Licence: CA 103202) | |
| Enumeration Date | 2012-05-22 |
| Last Update Date | 2021-01-18 |