| NPI | 1689994204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28807) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 57862) |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2020-01-20 |