| NPI | 1740641133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 33773) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 059261) |
| Enumeration Date | 2016-03-11 |
| Last Update Date | 2018-06-12 |