| NPI | 1164694626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD3305) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 56798) |
| Enumeration Date | 2008-03-25 |
| Last Update Date | 2021-10-04 |