| NPI | 1871293969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 41661) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2023-03-07 |
| Last Update Date | 2025-07-29 |