| NPI | 1700219300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 34999) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 62868) |
| Enumeration Date | 2013-08-19 |
| Last Update Date | 2022-11-17 |