| NPI | 1760676258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24344) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD2693) |
| 1223G0001X Dentist, General Practice (Licence: NM DD2693) | |
| Enumeration Date | 2007-08-28 |
| Last Update Date | 2023-06-12 |