| NPI | 1790347599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35215) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 7266) |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2021-09-28 |