| NPI | 1205125242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: TX 26249) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 63313) |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 63313) | |
| Enumeration Date | 2011-03-30 |
| Last Update Date | 2015-02-11 |