| NPI | 1760642045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID D4455) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 23966) |
| Enumeration Date | 2008-06-11 |
| Last Update Date | 2021-02-08 |