| NPI | 1053630780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 60303) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL10896) |
| 1223P0300X Dentist, Periodontics (Licence: CO 00201945) | |
| Enumeration Date | 2010-05-20 |
| Last Update Date | 2015-09-16 |