| NPI | 1790110732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 5865630-9924) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 9922) |
| Enumeration Date | 2013-09-10 |
| Last Update Date | 2022-04-04 |