| NPI | 1861464018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 9192) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27902) |
| 122300000X Dentist (Licence: AZ 8888) | |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2026-05-11 |