| NPI | 1013332063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO den.00204101) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 63223) |
| Enumeration Date | 2014-02-27 |
| Last Update Date | 2022-10-21 |