| NPI | 1891166922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35062) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 60959292) |
| 1223G0001X Dentist, General Practice (Licence: CA 64837) | |
| Enumeration Date | 2015-10-15 |
| Last Update Date | 2025-06-25 |