| NPI | 1124293543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 55809) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D9154) |
| Enumeration Date | 2008-04-26 |
| Last Update Date | 2010-04-07 |