| NPI | 1124173448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 46870) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 46870) |
| 1223G0001X Dentist General Practice (Licence: AZ 6683) | |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2015-08-12 |