| NPI | 1346362274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CA 37173) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: CA 37173) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2021-12-10 |