| NPI | 1396025540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 6309) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 61313) |
| Enumeration Date | 2011-08-19 |
| Last Update Date | 2014-09-03 |