| NPI | 1962879973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34712) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 018001960) |
| Enumeration Date | 2015-08-25 |
| Last Update Date | 2019-01-03 |