| NPI | 1033373576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00201966) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 57204) |
| 122300000X Dentist (Licence: NV 5937) | |
| Enumeration Date | 2008-07-14 |
| Last Update Date | 2013-07-01 |