| NPI | 1376959536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 63658) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0442000166) |
| Enumeration Date | 2014-07-09 |
| Last Update Date | 2014-07-15 |