| NPI | 1093792194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 51093) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00010611) |
| Enumeration Date | 2005-12-29 |
| Last Update Date | 2011-12-05 |