| NPI | 1841551264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 32639) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401414170) |
| 122300000X Dentist (Licence: MI 2901020709) | |
| 122300000X Dentist (Licence: CA 100990) | |
| Enumeration Date | 2012-06-01 |
| Last Update Date | 2022-07-21 |