| NPI | 1790006369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25503) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 25503) |
| Enumeration Date | 2010-06-18 |
| Last Update Date | 2021-01-19 |