| NPI | 1831505098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 32058) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: NM DD4140) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2018-08-27 |