| NPI | 1700903671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 9267) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 10690) |
| 1223G0001X Dentist, General Practice (Licence: TX 16977) | |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2024-09-18 |