| NPI | 1821170549 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: TX 19559) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 19559) |
| 1223G0001X Dentist, General Practice (Licence: TX 19559) | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 19559) | |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2021-09-22 |