| NPI | 1073765053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 60310) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: AZ 8188) |
| Enumeration Date | 2008-10-21 |
| Last Update Date | 2012-05-29 |