| NPI | 1164707808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4634) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 60878) |
| 1223G0001X Dentist, General Practice (Licence: CA 60878) | |
| 1223G0001X Dentist, General Practice (Licence: CT 11088) | |
| Enumeration Date | 2011-10-13 |
| Last Update Date | 2017-02-13 |