| NPI | 1366655201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 55524) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 55524) |
| 1223G0001X Dentist, General Practice (Licence: MN D11812) | |
| Enumeration Date | 2007-05-08 |
| Last Update Date | 2010-11-04 |