| NPI | 1912259631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28458) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: VA 0401418135) |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2022-10-03 |