| NPI | 1932161163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 26214) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 26214) |
| 1223G0001X Dentist General Practice (Licence: NY 052050) | |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2023-03-31 |