| NPI | 1225197734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 37519) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 37519) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 37519) | |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2019-06-03 |