| NPI | 1386603827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 34007) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901013842) |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2007-07-08 |