| NPI | 1043590482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: CA 60610) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS60610) |
| 122300000X Dentist (Licence: NM DD3544) | |
| Enumeration Date | 2011-08-17 |
| Last Update Date | 2020-11-17 |