| NPI | 1194070110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 101391) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856087) |
| 122300000X Dentist (Licence: OR DF0027) | |
| 122300000X Dentist (Licence: KY 4887) | |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2017-06-02 |