| NPI | 1932161825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: UT 52028788903) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NM DD3479) |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2011-06-23 |