| NPI | 1770606204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35042) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 8093) |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2020-09-02 |