| NPI | 1396800702 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 10264) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 38118) |
| Enumeration Date | 2006-12-26 |
| Last Update Date | 2014-07-18 |