| NPI | 1194897660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25065) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 53181) |
| 122300000X Dentist (Licence: WI 5331-015) | |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2010-04-19 |