| NPI | 1801180757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 27091) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 27091) | |
| Enumeration Date | 2011-06-07 |
| Last Update Date | 2013-07-03 |