| NPI | 1740285014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 7045) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 19200) |
| 1223G0001X Dentist, General Practice (Licence: CA 48519) | |
| 1223G0001X Dentist, General Practice (Licence: NM DD4330) | |
| 1223G0001X Dentist, General Practice (Licence: AZ 3964) | |
| Enumeration Date | 2005-06-14 |
| Last Update Date | 2020-03-17 |