| NPI | 1053715698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 63958) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 63958) |
| Enumeration Date | 2014-10-10 |
| Last Update Date | 2020-03-02 |