| NPI | 1720412992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 30087) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019029620) |
| 1223G0001X Dentist General Practice (Licence: TX 30087) | |
| Enumeration Date | 2013-08-24 |
| Last Update Date | 2022-10-28 |