| NPI | 1215333547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 63465) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 63465) |
| Enumeration Date | 2014-11-13 |
| Last Update Date | 2016-09-28 |