| NPI | 1922554781 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 38217) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV WV4229) |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2022-06-16 |