| NPI | 1336369750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: GU D1034) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: CA 62275) |
| 1223P0300X Dentist, Periodontics (Licence: MD 13473) | |
| 1223P0300X Dentist, Periodontics (Licence: CA DDS62275) | |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2021-01-05 |