| NPI | 1386900504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 64365) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 50 056784) |
| Enumeration Date | 2012-04-02 |
| Last Update Date | 2015-04-29 |