| NPI | 1265648570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist Dentist Anesthesiologist (Licence: CA G1032) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 40215) |
| 122300000X Dentist (Licence: CA D40215) | |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2013-05-20 |