| NPI | 1972549418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 5329217-9922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 5329217-9922) |
| 332B00000X Durable Medical Equipment & Medical Supplies (Licence: UT 5329217-9922) | |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: UT 5329217-9922) | |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2018-12-07 |