| NPI | 1346780715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 103757) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 11775) |
| Enumeration Date | 2017-03-03 |
| Last Update Date | 2019-09-05 |