| NPI | 1174748123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 64198) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 053328) |
| Enumeration Date | 2007-04-16 |
| Last Update Date | 2016-05-13 |