| NPI | 1821515982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37128) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1001579-15) |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2022-05-03 |