| NPI | 1023459856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 63670) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856195) |
| 122300000X Dentist (Licence: CA 63670) | |
| Enumeration Date | 2013-07-09 |
| Last Update Date | 2018-09-07 |