| NPI | 1740559210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 27928) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 7103) |
| Enumeration Date | 2011-12-29 |
| Last Update Date | 2022-05-24 |