| NPI | 1780857078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 26215) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8542) |
| 1223G0001X Dentist, General Practice (Licence: TN DS0000010189) | |
| 1223G0001X Dentist, General Practice (Licence: TX 26215) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OK 335) | |
| Enumeration Date | 2008-04-08 |
| Last Update Date | 2025-05-05 |