| NPI | 1154603652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11062) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 60517) |
| 122300000X Dentist (Licence: TX 30429) | |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2019-12-19 |