| NPI | 1902391972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 35899) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS041744) |
| Enumeration Date | 2018-06-22 |
| Last Update Date | 2023-08-14 |