| NPI | 1760400022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: TX 27851) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: NE 5891) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2014-08-07 |