| NPI | 1275932188 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA DDS101338) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856699) |
| Enumeration Date | 2014-08-15 |
| Last Update Date | 2020-06-18 |