| NPI | 1811159759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D9114) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D9114) |
| 1223G0001X Dentist, General Practice (Licence: TX 24530) | |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2020-10-06 |