| NPI | 1790110328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 29438) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 29438) |
| Enumeration Date | 2013-09-13 |
| Last Update Date | 2013-09-13 |