| NPI | 1306361845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 104751) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6831) |
| Enumeration Date | 2017-08-05 |
| Last Update Date | 2020-08-26 |