| NPI | 1710400171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34395) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 104203469921) |
| Enumeration Date | 2017-07-18 |
| Last Update Date | 2022-12-01 |