| NPI | 1912161902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 29966) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.027597) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: NY 50053909) | |
| Enumeration Date | 2008-07-18 |
| Last Update Date | 2014-09-26 |