| NPI | 1386027704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 101260) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1856836) |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2017-04-27 |