| NPI | 1912573205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 37274) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 12269263-9923) |
| Enumeration Date | 2021-05-28 |
| Last Update Date | 2021-11-09 |