| NPI | 1295018547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 60198) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27535) |
| Enumeration Date | 2011-09-23 |
| Last Update Date | 2022-01-28 |