| NPI | 1982086807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: TX 30959) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 30959) |
| 1223G0001X Dentist, General Practice (Licence: TX 30959) | |
| Enumeration Date | 2015-06-27 |
| Last Update Date | 2023-07-24 |