| NPI | 1902118177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD3412) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 25439) |
| Enumeration Date | 2010-07-05 |
| Last Update Date | 2019-03-03 |