| NPI | 1336138296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 60005) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AZ 6406) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2020-07-21 |