| NPI | 1215274865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401415308) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 61791) |
| Enumeration Date | 2013-01-15 |
| Last Update Date | 2016-09-26 |