| NPI | 1740666536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4374) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 36819) |
| Enumeration Date | 2015-08-04 |
| Last Update Date | 2021-01-14 |