| NPI | 1114308442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN 21268) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS100138) |
| Enumeration Date | 2015-06-11 |
| Last Update Date | 2019-01-16 |