| NPI | 1205855293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 49561) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 056821) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2019-04-09 |