| NPI | 1770863136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: TX 25766) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 25766) |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2023-06-15 |