| NPI | 1063712909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD2954) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 45689) |
| Enumeration Date | 2010-10-26 |
| Last Update Date | 2012-03-15 |