| NPI | 1710042478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 26298) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 4994T) |
| 1223G0001X Dentist, General Practice (Licence: CA 39024) | |
| Enumeration Date | 2006-12-23 |
| Last Update Date | 2015-07-21 |