| NPI | 1013140672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 58576) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 25145) |
| Enumeration Date | 2009-08-31 |
| Last Update Date | 2010-02-24 |