| NPI | 1043566706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: CA 61279) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 61279) |
| 122300000X Dentist (Licence: CO 202272) | |
| 174400000X Specialist (Licence: CO 202272) | |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment | |
| Enumeration Date | 2012-07-31 |
| Last Update Date | 2020-09-03 |