| NPI | 1740665785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 20297) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 31047) |
| Enumeration Date | 2015-07-20 |
| Last Update Date | 2026-03-03 |