| NPI | 1811346042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 34947) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401415235) |
| Enumeration Date | 2016-06-08 |
| Last Update Date | 2019-07-11 |