| NPI | 1154457851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 4158) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 37060) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2016-03-04 |