| NPI | 1699221275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 9829508-8903) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9829508-9922) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2016-09-01 |