| NPI | 1780224915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 39450) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 12873) |
| 1223P0700X Dentist, Prosthodontics (Licence: TX 39450) | |
| Enumeration Date | 2020-01-15 |
| Last Update Date | 2025-09-11 |