| NPI | 1326379553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR 09555) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 58350) |
| Enumeration Date | 2010-01-28 |
| Last Update Date | 2011-04-01 |