| NPI | 1770046864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD5372) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 34874) |
| Enumeration Date | 2019-04-07 |
| Last Update Date | 2020-11-12 |