| NPI | 1013204627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 63373) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD3515) |
| Enumeration Date | 2011-07-03 |
| Last Update Date | 2014-07-29 |