| NPI | 1245247097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA DDS102131) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00010455) |
| 122300000X Dentist (Licence: FL DN14848) | |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2021-05-28 |