| NPI | 1760903280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204659) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 34958) |
| 122300000X Dentist (Licence: NM DD4735) | |
| Enumeration Date | 2017-07-06 |
| Last Update Date | 2022-02-23 |