| NPI | 1194049072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA dds101014) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 054819) |
| 1223G0001X Dentist, General Practice (Licence: CT 010241) | |
| Enumeration Date | 2010-03-20 |
| Last Update Date | 2016-12-13 |