| NPI | 1013267954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: AL 5968) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: CA 61911) |
| Enumeration Date | 2012-09-18 |
| Last Update Date | 2014-07-09 |