| NPI | 1073665386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 46437) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 3744) |
| 122300000X Dentist (Licence: AZ 6900) | |
| 122300000X Dentist (Licence: OR D7680) | |
| 122300000X Dentist (Licence: WA DE8866) | |
| Enumeration Date | 2007-01-17 |
| Last Update Date | 2012-08-09 |