| NPI | 1295079747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 61094) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 00201888) |
| Enumeration Date | 2012-11-22 |
| Last Update Date | 2015-05-13 |