| NPI | 1003243049 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 60385) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 15302) |
| 122300000X Dentist (Licence: VA 15302) | |
| Enumeration Date | 2013-10-04 |
| Last Update Date | 2020-04-20 |