| NPI | 1215272109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 61625) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 61625) |
| Enumeration Date | 2012-12-03 |
| Last Update Date | 2023-03-07 |