| NPI | 1124241575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 48376) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 48376) |
| Enumeration Date | 2007-04-11 |
| Last Update Date | 2020-11-20 |