| NPI | 1710290028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25794) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0025794) |
| 1223G0001X Dentist, General Practice (Licence: TX 25794) | |
| Enumeration Date | 2010-07-16 |
| Last Update Date | 2022-03-07 |