| NPI | 1174871560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 102400) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020799) |
| Enumeration Date | 2012-08-16 |
| Last Update Date | 2018-11-26 |