| NPI | 1366776692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 6811888-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 54882) |
| Enumeration Date | 2009-09-18 |
| Last Update Date | 2011-06-27 |