| NPI | 1902265440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D11819) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 33984) |
| Enumeration Date | 2016-02-11 |
| Last Update Date | 2025-04-15 |