| NPI | 1346490802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 54726) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: WA 60113224) |
| Enumeration Date | 2008-09-22 |
| Last Update Date | 2009-11-23 |