| NPI | 1760896658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31714) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2014018885) |
| Enumeration Date | 2014-06-18 |
| Last Update Date | 2018-01-31 |