| NPI | 1790104891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 33942) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: LA 6834) |
| Enumeration Date | 2014-04-16 |
| Last Update Date | 2025-11-20 |