| NPI | 1265632715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D9097) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OR D9097) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 55033) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 55033) | |
| Enumeration Date | 2007-07-23 |
| Last Update Date | 2009-12-15 |