| NPI | 1104016765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 39398) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 39398) |
| Enumeration Date | 2007-07-30 |
| Last Update Date | 2015-04-08 |