| NPI | 1912255803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: HI 2682) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 61756) |
| 1223G0001X Dentist, General Practice (Licence: TX 28824) | |
| Enumeration Date | 2012-08-27 |
| Last Update Date | 2023-11-01 |