| NPI | 1790194561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30325) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 63835) |
| Enumeration Date | 2014-08-06 |
| Last Update Date | 2016-08-17 |