| NPI | 1316131022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 101663) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 8696) |
| Enumeration Date | 2007-09-05 |
| Last Update Date | 2019-10-16 |