| NPI | 1104018753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D07729) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 204919754) |
| Enumeration Date | 2007-08-16 |
| Last Update Date | 2024-11-14 |