| NPI | 1003979584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 30951) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 6965) |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2025-05-20 |