| NPI | 1942500970 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30881) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PR 2859) |
| Enumeration Date | 2010-10-25 |
| Last Update Date | 2016-04-27 |