| NPI | 1891978904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 23540) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 23540) |
| 1223G0001X Dentist, General Practice (Licence: IL 019.027518) | |
| Enumeration Date | 2007-12-12 |
| Last Update Date | 2021-07-23 |