| NPI | 1942564539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27931) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 6835) |
| Enumeration Date | 2012-06-27 |
| Last Update Date | 2018-07-08 |