| NPI | 1720123946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 18458) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 8054) |
| 1223G0001X Dentist General Practice (Licence: MI 2901009941) | |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2007-07-08 |