| NPI | 1982120895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TX 34858) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2017020610) |
| 1223G0001X Dentist, General Practice (Licence: TX 34858) | |
| Enumeration Date | 2017-08-22 |
| Last Update Date | 2023-08-20 |