| NPI | 1720107717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 13820) |
| Additional Taxonomies | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: TX 13820) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2014-10-23 |