| NPI | 1962899294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 32494) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 32494) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-04-24 |
| Last Update Date | 2021-05-24 |