| NPI | 1760767230 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27343) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: UT 80174279922) |
| Enumeration Date | 2011-10-17 |
| Last Update Date | 2018-02-08 |