| NPI | 1730666595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 39190) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 102674) |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2023-05-03 |