| NPI | 1700195823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 25667) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: TX 25667) |
| Enumeration Date | 2010-10-07 |
| Last Update Date | 2016-02-29 |