| NPI | 1881035749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 64381) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 29225) |
| 1223G0001X Dentist, General Practice (Licence: TX 29225) | |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2024-02-28 |