| NPI | 1992969968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 29513) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 10135) |
| Enumeration Date | 2008-07-17 |
| Last Update Date | 2015-07-08 |