| NPI | 1265735542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: CA 62070) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 50054647) |
| Enumeration Date | 2010-12-08 |
| Last Update Date | 2013-02-08 |