| NPI | 1134538804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 64309) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401414571) |
| Enumeration Date | 2014-08-07 |
| Last Update Date | 2018-12-20 |