| NPI | 1790092757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 10262) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24703) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2021-09-15 |