| NPI | 1780687210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 14215) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 14215) |
| Enumeration Date | 2005-05-30 |
| Last Update Date | 2019-06-10 |