| NPI | 1750953485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 14285379) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 37241) |
| 1223G0001X Dentist, General Practice (Licence: CO DEN.00206392) | |
| Enumeration Date | 2021-07-13 |
| Last Update Date | 2026-07-02 |