| NPI | 1730440934 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31668) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 5888464-9922) |
| Enumeration Date | 2012-06-04 |
| Last Update Date | 2016-07-04 |