| NPI | 1871675967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 17468) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 17468) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2022-11-21 |