| NPI | 1831326925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 25289) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25289) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: TX 25289) | |
| Enumeration Date | 2009-06-16 |
| Last Update Date | 2018-06-05 |