| NPI | 1104074079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 28791) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 10964170-9921) |
| Enumeration Date | 2008-09-04 |
| Last Update Date | 2021-11-23 |