| NPI | 1831350222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 29771) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NY 054395-1) |
| Enumeration Date | 2008-06-19 |
| Last Update Date | 2021-06-07 |