| NPI | 1912153214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 20892) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: TX 20892) |
| Enumeration Date | 2008-08-18 |
| Last Update Date | 2013-12-17 |