| NPI | 1770869877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 27480) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 14374) |
| Enumeration Date | 2011-11-02 |
| Last Update Date | 2011-11-02 |