| NPI | 1942267935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 008698) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 046043) |
| 122300000X Dentist (Licence: PA DS038562) | |
| 122300000X Dentist (Licence: TX 27827) | |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2015-12-31 |