| NPI | 1134104052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 60240) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS036205) |
| Enumeration Date | 2005-12-13 |
| Last Update Date | 2015-02-28 |