| NPI | 1780316380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 40286) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 51343) |
| Enumeration Date | 2022-06-30 |
| Last Update Date | 2025-06-26 |