| NPI | 1073897658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 27420) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 62083) |
| Enumeration Date | 2011-09-30 |
| Last Update Date | 2015-12-16 |