| NPI | 1205858693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM 1297) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 50877) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2015-03-28 |