| NPI | 1972941144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30529) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 057526) |
| Enumeration Date | 2013-06-11 |
| Last Update Date | 2015-09-08 |