| NPI | 1205868494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 36343) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 2514) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2013-12-27 |