| NPI | 1184709487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 55688) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 21440) |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2011-10-20 |