| NPI | 1972767176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist Dentist Anesthesiologist (Licence: TX 18772) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 18772) |
| 1223P0221X Dentist Pediatric Dentistry (Licence: WA DE00010026) | |
| Enumeration Date | 2008-07-16 |
| Last Update Date | 2022-02-14 |